Doctor Information

Previous consultations:Three weeks ago:Seen by Jeremy Jones (Health Care Assistant): 16:59 pmBooked in for a Health Check with the Dr in three weeks time, came in for blood tests and vitals recording.Height: 178cmWeight: 105kgBMI: 33.2Pulse: 83 regularBlood Pressure: 148/78Bloods taken today.

Four days ago:HbA1c: 44mmol/molPlan: book appointment to discuss results with GP

Patient Information

Gilbert Metcalf, age 49

Opening Line: I’ve been told that you wanted to see me, I’m guessing it’s about my blood tests.

History: You already know about your results, as you’ve already asked reception. You’re aware that your blood sugars are high, and you’re really concerned about the effect this is going to have on you (more about this below). You’ve done some reading, and you feel that you need to start treatment straight away, you’re not happy about metformin, as you’ve got a lot of friends that have had that medication and not tolerated it. Instead you’ve found something called Lixisenatide, which promises to help you lose weight and also reduce your blood sugar. You are aware that it is an injection, but you’re still happy to proceed.

Past Medical History: You’ve not really had any medical problems up until now except for some rhinitis that affects you mainly in the summer months. You take a nasal spray for this on a semi-regular basis. You've had no operations, and have not been tested for blood sugar before now.

Social History: You’ve never smoked. You share a bottle of wine with you wife 5 nights a week. You are aware that you’re overweight, and that this is down to your love of chocolates. You find that it is your greatest vice, and that this is one of the ways you relieve stress. You work as a chancellor for the local University, and the job involves long hours. You don’t find much time to exercise currently on your days off as you feel exhausted from the working week.

Family History: You are the youngest of three brothers. One of your other siblings, and your mother has diabetes. Your mothers diabetes is bad, and is currently controlled with insulin. Unfortunately she had to have her leg amputated a few months back, and this is a big word for you (see more below)

Ideas and concerns:You think that you have the beginnings of diabetes, and you are in one way happy that it has been caught early, as it means that you can start treatment straight away and hopefully help prevent future complications.

You’re very concerned about the risks of complications, you know about possible problems with kidneys, vision, and amputations. You feel that everyone with diabetes will eventually suffer one of these complications, and this scares you.

Expectations:After reading about treatment options, you are really keen to start lixisenatide, as it can help you lose weight and keep your blood sugars low. You’re not keen on taking metformin, as you’ve known friends who haven't tolerated it.

Examination Findings

Examination

No examination required in this case.

Mark scheme

Data Gathering

POSITIVE INDICATORS

Organised and systematic approach to data gathering, without making any assumptions

Unable to explain probable causality or role of current lifestyle in pre-diabetes

Unclear about timeframe for follow up

Safety netting absent or incomplete

Agrees to start unlicensed medication or prescribes outside of guidance​Doesn’t recommend Intensive lifestyle intervention for management in this case.

Inter Personal Skills

POSITIVE INDICATORS

Identifies the patient’s health beliefs, their agenda, and their ICE

Establishes concern for diabetic complications.

Uses explanations that are relevant and understandable to the patient, and lacking in jargon

Shows sensitivity and empathy for the patient’s feelings​Works with the patient to develop a shared management plan

NEGATIVE INDICATORS

Fails to identify the patient’s heath beliefs, agenda or ICE

Doesn’t establish concern for diabetic complications.

Explanation absent or filled with jargon

Fails to empathise with the patient’s situation​Uses a doctor centred approach

Management

This case requires you to know and be confident about Pre-diabetes, in order to challenge the patient’s expectations regarding treatment.

Let’s start with a patient explanation:

Everyone has sugar in their blood, it’s normal and an important source of energy. If the blood sugars are very high, we would call this diabetes. Pre diabetes is when your blood sugars are higher than normal, but not quite high enough to be called diabetes. We know that 5-10% of people with pre-diabetes go onto develop diabetes each year, and that we need to act now if we wish to reduce this risk.

Diagnosis:Pre-diabetes is not a condition recognised by WHO, however NICE suggests a HbA1c between 42-47 mmol/mol (6.0-6.4%) or a Fasting Plasma Glucose of 5.5-6.9 be considered as ‘high risk’ of developing diabetes, and is generally considered the range consistent with diagnosis of pre-diabetes, but please be aware that lab ranges can vary locally.

Unlike diabetes, there is no recommendation re how many tests should be done before diagnosing the condition, however common sense would dictate more than one, in case of let errors etc..

The bit we are interested in is the management of the high risk group. NICE suggests that the mainstay of management should be intensive lifestyle-change programme, please see below for more details:

Intensive Lifestyle Change Programme

Reducing weight so that BMI is below 25 (or 23 if of South Asian, or Chinese descent)

Aim to reduce 5-10% of body weight by reducing caloric intake

Increase dietary fibre intake

Choose foods that are lower in saturated fats

Choose skimmed or semi-skimmed products

Choose fish and lean meats instead of processed meats

Avoid frying or roasting food

Avoid high sugar foods (cakes, chocolates, biscuits etc..)

If BMI above 30 (27.5 is of South Asian or Chinese descent) offer a structured weight loss programme.

Another options is the 5:2 diet, which some patients can find easier to adhere to, and can yield good results. If you’re unfamiliar with the 5:2 diet, a patient information leaflet can be accessed here: (http://patient.info/health/52-diet)

Increasing exercise levels to 150minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity activity. if this is unachievable, emphasise that even a small increase in exercise levels can be beneficial.

The Use of MedicationNICE suggests that medication should only be started if:

Patients are unable to undertake the above programme, or if,

Despite participation, blood sugar readings show that they are still progressing towards diabetes.

The only hypoglycaemic agent currently recommended is Metformin. In this particular case Lixisenatide could not be used, as it is not licensed nor recommended.

The only other medication for pre-diabetes that is recommended by NICE is Orlistat, if the BMI is >28 and they are:

Unable to undertake intensive lifestyle change (due to a disability or a medical reason)

Not benefitting from the intensive lifestyle-change programme

Last Edited: 09/08/16

CSA Revision; owned and operated by LaneApps Limited, No: 08950053

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This case requires you to know and be confident about Pre-diabetes, in order to challenge the patient’s expectations regarding treatment.

Let’s start with a patient explanation:

Everyone has sugar in their blood, it’s normal and an important source of energy. If the blood sugars are very high, we would call this diabetes. Pre diabetes is when your blood sugars are higher than normal, but not quite high enough to be called diabetes. We know that 5-10% of people with pre-diabetes go onto develop diabetes each year, and that we need to act now if we wish to reduce this risk.